Update of Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS))-Part A

Abstract

In 2014, the International Endohernia Society (IEHS) published the first international “Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias.” Guidelines reflect the currently best available evidence in diagnostics and therapy and give recommendations to help surgeons to standardize their techniques and to improve their results. However, science is a dynamic field which is continuously developing. Therefore, guidelines require regular updates to keep pace with the evolving literature.

Methods

For the development of the original guidelines, all relevant literature published up to year 2012 was analyzed using the ranking of the Oxford Centre for Evidence-Based Medicine. For the present update, all of the previous authors were asked to evaluate the literature published during the recent years from 2012 to 2017 and revise their statements and recommendations given in the initial guidelines accordingly. In two Consensus Conferences (October 2017 Beijing, March 2018 Cologne), the updates were presented, discussed, and confirmed. To avoid redundancy, only new statements or recommendations are included in this paper. Therefore, for full understanding both of the guidelines, the original and the current, must be read. In addition, the new developments in repair of abdominal wall hernias like surgical techniques within the abdominal wall, release operations (transversus muscle release, component separation), Botox application, and robot-assisted repair methods were included.

Results

Due to an increase of the number of patients and further development of surgical techniques, repair of primary and secondary abdominal wall hernias attracts increasing interests of many surgeons. Whereas up to three decades ago hernia-related publications did not exceed 20 per year, currently this number is about 10-fold higher. Recent years are characterized by the advent of new techniques—minimal invasive techniques using robotics and laparoscopy, totally extraperitoneal repairs, novel myofascial release techniques for optimal closure of large defects, and Botox for relaxing the abdominal wall. Furthermore, a concomitant rectus diastasis was recognized as a significant risk factor for recurrence. Despite insufficient evidence with respect to these new techniques, it seemed to us necessary to include them in the update to stimulate surgeons to do research in these fields.

Conclusion

Guidelines are recommendations based on best available evidence intended to help the surgeon to improve the quality of his daily work. However, science is a continuously evolving process, and as such guidelines should be updated about every 3 years. For a comprehensive reference, however, it is suggested to read both the initial guidelines published in 2014 together with the update. Moreover, the presented update includes also techniques which were not known 3 years before.

Minimally Invasive Anal Fistula Treatment (MAFT)-An Appraisal of Early Results in 416 Patients

Minimally invasive anal fistula treatment (MAFT) was introduced to minimize early postoperative morbidity, preserve sphincter continence, and reduce recurrence. We report our early experience with MAFT in 416 patients. Preoperative MRI was performed in 150 patients initially and subsequently thereafter. The technique involves fistuloscope-aided localization of internal fistula opening, examination and fulguration of all fistula tracks, and secure stapled closure of internal fistula opening within anal canal/rectum. MAFT was performed as day-care procedure in 391 patients (93.9 %). During surgery, internal fistula opening could not be located in 100 patients (24 %). Seven patients required readmission to hospital. Mean visual analog scale scores for pain on discharge and at 1 week were 3.1 (1-6) and 1.6 (0-3), respectively. Mean duration for return to normal activity was 3.2 days (2-11 days). Fistula recurrence was observed in 35/134 patients (26.1 %) at 1 year follow-up. MAFT may be performed as day-care procedure with benefits of less pain, absence of perianal wounds, faster recovery, and preservation of sphincter continence. However, long-term results from more centers are needed especially for recurrence.

[Not Available]

Spigelian hernia occurs through slit like defect in the anterior abdominal wall adjacent to the semilunar line. Most of spigelian hernias occur in the lower abdomen where the posterior sheath is deficient. The hernia ring is a well-defined defect in the transverses aponeurosis. The hernial sac, surrounded by extraperitoneal fatty tissue, is often interparietal passing through the transversus and the internal oblique aponeuroses and then spreading out beneath the intact aponeurosis of the external oblique. Spigelian hernia is in itself very rare and more over it is difficult to diagnose clinically. It has been estimated that it constitutes 0.12% of abdominal wall hernias. The spigelian hernia has been repaired by both conventional and laparoscopic approach. Laparoscopic management of spigelian hernia is well established. Most of the authors have managed it by transperitoneal approach either by placing the mesh in intraperitoneal position or by raising the peritoneal flap and placing the mesh in extraperitoneal space. There have also been case reports of management of spigelian hernia by total extraperitoneal approach. We retrospectively reviewed our experience of ten patients between 1997 and 2007. Eight patients (8/10) presented with abdominal pain and two patients (2/10) were asymptomatic. In six patients (6/10) we performed an intraperitoneal onlay IPOM repair, in two patients (2/10) transabdominal preperitoneal repair (TAPP), and in two (2/10) total extraperitoneal repair (TEP). There were no recurrences, or other morbidity at mean follow up period of 3.2 years (range 6 months to 10 years).

Iatrogenic enterotomy in laparoscopic ventral/incisional hernia repair: a single center experience of 2,346 patients over 17 years

PURPOSE

Iatrogenic enterotomy (IE) during laparoscopic ventral/incisional hernia repair (LIVHR) is reported to be associated with poorer surgical outcomes. We report our experience with diagnosis, management and complications in patients who had IE during LIVHR at our tertiary referral institute between 1994 and 2011.

METHODS

We retrospectively reviewed prospectively collected data of 2,346 patients who underwent LIVHR from 1994 to 2011. We identified 33 patients who had IE during LIVHR. All surgical procedures were performed by five consultants and fellows under supervision who followed a standardized operative protocol. Patients were followed up for 6 months to evaluate morbidity, mortality, additional surgical procedures, unplanned readmissions and hospital stay.

RESULTS

Mortality occurred in 2 patients (6 %). Complications occurred in 16 patients (48.5 %). Median hospital stay was 3 days (2-36). Unplanned readmission was required in 6 patients (18 %). In 18 patients, (55 %) additional surgical procedures were required within 6 months of LIVHR. In 5 patients, the enterotomy was recognized postoperatively. These patients had worst outcomes [mortality 40 %, additional surgical procedures were required in all patients (100 %) and median hospital stay was 12 days (range 7-36)].

CONCLUSION

Iatrogenic enterotomy is a serious complication during LIVHR. IE is associated with mortality, morbidity, additional surgical procedures, unplanned readmissions and prolonged hospital stay. In patients where IE was recognized postoperatively, the prognosis was worst.

Single port versus multiple port laparoscopic cholecystectomy-a comparative study

Single port laparoscopic cholecystectomy (SPLC) was introduced to minimize postoperative morbidity and improve cosmesis. We performed a comparative study to assess feasibility, safety and perceived benefits of SPLC. Two groups of patients (104 each) with comparable demographic characteristics were selected for SPLC and multiport laparoscopic cholecystectomy (MPLC) between May 2010 to March 2011. SPLC was performed using X cone® with 5 mm extra long telescope and 3 ports for hand instruments. MPLC was performed with traditional 4 port technique. A large window was always created during dissection to obtain the critical view of safety. Data collection was prospective. The primary end points were post-operative pain and surgical complications. Secondary end points were patient assessed cosmesis and satisfaction scores and operating time. The mean VAS scores for pain in SPLC group were higher on day 0 (SPLC 3.37 versus MPLC 2.72, p = 0.03) and equivalent to MPLC group on day 1(SPLC 1.90 versus MPLC 1.79, p = 0.06). Number of patients requiring analgesia for breakthrough pain (SPLC 21.1 % versus MPLC 26.9 %, p = 0.31) was similar. Number and nature of surgical complications was similar (SPLC 17.3 % versus MPLC 21.2 %, p =0.59). Mean patient assessed cosmesis scores (SPLC 7.96 versus MPLC 7.16, p = 0.003) and mean patient satisfaction scores (SPLC 8.66 versus MPLC 8.16, p = 0.004) were higher in SPLC group indicating better cosmesis and greater patient satisfaction. SPLC took longer to perform (61 min versus 26 min, p = 0.00). Conversion was required in 5 patients in SPLC group. SPLC appears to be feasible and safe with cosmetic benefits in selected patients. However, challenges remain to improve operative ergonomics. SPLC needs to be proven efficacious with a high safety profile to be accepted as standard laparoscopic technique.

Laparoscopic transabdominal extraperitoneal repair of lumbar hernia

Lumbar hernias need to be repaired due to the risk of incarceration and strangulation. A laparoscopic intraperitoneal approach in the modified flank position causes the intraperitoneal viscera to be displaced medially away from the hernia. The creation of a wide peritoneal flap around the hernial defect helps in mobilization of the colon, increased length of margin is available for coverage of mesh and more importantly for secure fixation of the mesh under vision to the underlying fascia. Laparoscopic lumbar hernia repair by this technique is a tensionless repair that diffuses total intra-abdominal pressure on each square inch of implanted mesh. The technique follows current principles of hernia repair and appears to confer all benefits of a minimal access approach.

Endoscopic neck surgery

Endoscopic surgery in the neck was attempted in 1996 for performing parathyroidectomy. A similar surgical technique was used for performing thyroidectomy the following year. Most commonly reported endoscopic neck surgery studies in literature have been on thyroid and parathyroid glands. The approaches are divided into two types i.e., the total endoscopic approach using CO(2) insufflation and the video-assisted approach without CO(2) insufflation. The latter approach has been reported more often. The surgical access (port placements) may vary-the common sites are the neck, anterior chest wall, axilla, and periareolar region. The limiting factors are the size of the gland and malignancy. Few reports are available on endoscopic resection for early thyroid malignancy and cervical lymph node dissection. Endoscopic neck surgery has primarily evolved due to its cosmetic benefits and it has proved to be safe and feasible in suitable patients with thyroid and parathyroid pathologies. Application of this technique for approaching other cervical organs such as the submandibular gland and carotid artery are still in the early experimental phase.

Laparoscopic ventral/incisional hernia repair: a single centre experience of 1,242 patients over a period of 13 years

BACKGROUND AND PURPOSE

Laparoscopic technique is now well established for ventral/incisional hernia repair. However several issues such as optimal fixation technique, occult hernias, management of inadvertent enterotomies, postoperative seromas and recurrence require appraisal.

METHODS

A single centre retrospective review of 1,242 patients between January 1992 and June 2005 is described. All patients had laparoscopic ventral/incisional hernia repair (LVIHR) following a standardised protocol by five consultants and fellows in a dedicated minimal access surgery unit of a tertiary care hospital.

RESULTS

LVIHR was completed in 1,223 patients (98.5%). The average BMI was 32, mean defect size was 26.2 cm(2), mean operating time was 81 min and mean hospital stay was 1.9 days. The mean mesh to hernia ratio was 37.5. Occult hernias were observed in 203 (16.3%) patients and inadvertent enterotomies occurred in 21 (1.7%) patients. Mortality occurred in two patients, pulmonary embolism and cardiac dysrhythmia being the respective reasons. The most common sequel was early seroma formation (25%). Chronic pain occurred in 14.7% patients. Recurrence rate was 4.4%, which was associated with a higher BMI, use of staplers as fixation device, multiple defects and recurrent hernias. The mean follow up was 5.4 years; (range 2.4-10 years). The follow up rate was 78%.

CONCLUSION

LVIHR leads to low recurrence rates and low rates of wound and mesh infection. Occult hernias are diagnosed and optimally treated laparoscopically. However, chronic pain remains an unresolved issue.

Prospective randomized clinical trial comparing lightweight mesh and heavyweight polypropylene mesh in endoscopic totally extraperitoneal groin hernia repair

BACKGROUND

The purported advantage of lightweight large-pore meshes is improved biocompatibility that translates into lesser postoperative pain and earlier rehabilitation. However, there are concerns of increased hernia recurrence rate. We undertook a prospective randomized clinical trial to compare early and late outcome measures with the use of a lightweight (Ultrapro) mesh and heavyweight (Prolene) mesh in endoscopic totally extraperitoneal (TEP) groin hernia repair.

METHODS

A prospective study was performed on 402 patients (191 in Ultrapro and 211 in Prolene group) with bilateral groin hernias who underwent endoscopic TEP groin hernia repair from March 2006 to June 2007. All operations were performed by five consultants following a standardized operative protocol. Chronic groin pain and hernia recurrence were evaluated as primary outcome measures. Secondary outcome measure were early postoperative pain, operative time, number of fixation devices required to fix the mesh, return to normal daily activities of work, seroma, and testicular pain.

RESULTS

At 1-year follow-up, incidence in Ultrapro versus Prolene group for chronic groin pain was 1.6% vs. 4.7% (p = 0.178) and recurrence was 1.3% vs. 0.2% (p = 0.078). In Ultrapro versus Prolene group, mean visual analogue score for postoperative pain at day 7 was 1.07 vs. 1.31 (p = 0.00), mean return to normal activities was 1.82 vs. 2.09 days (p = 0.00), and mean number of fixation devices per patient required to fix the mesh was 4.22 vs. 4.08 (p = 0.043).

CONCLUSION

Lightweight meshes appear to have advantages in terms of lesser pain and early return to normal activity. However, more patients had hernia recurrence with lightweight meshes, especially for larger hernias. We surmise that the lightweight meshes have greater tendency to get displaced from their intended position during desufflation at the conclusion of endoscopic TEP repair.

Laparoscopic sleeve gastrectomy: an Indian experience-surgical technique and early results

BACKGROUND

Obesity has been observed to be on the rise in the Indian subcontinent. We report our early experience with the laparoscopic sleeve gastrectomy (LSG) for treating morbid obesity in the Indian population along with description of the surgical technique.

METHODS

The data of 75 patients who underwent LSG for the treatment of morbid obesity at the Minimal Access, Metabolic and Bariatric Surgery Centre, Sir Ganga Ram Hospital, Delhi, from November 2006 to February 2009, were retrospectively reviewed from prospective database. The gastric sleeve is created laparoscopically using sequential firings of a linear stapling device applied alongside a 36-Fr calibrating bougie. The data collected included age, gender, initial body mass index (BMI) and excess weight, the co-morbidity status, and preoperative investigations. Perioperative parameters and follow-up details [weight, BMI, excess weight loss (%EWL), resolution of co-morbidities, and postoperative investigations] were noted.

RESULTS

All procedures were completed laparoscopically. There was no major procedure-related morbidity. Hemorrhage requiring blood transfusion was observed in four patients. One patient died at 2 weeks postoperatively due to pulmonary embolism. There was a steady rise in %EWL from 31.2% at 3 months to 52.3% at 6 months, 59.13% at 1 year, and 65% at 2 years. Type II diabetes was resolved in 81.2%, hypertension in 93.75%, and dyslipidemia in 85% at 1 year.

CONCLUSION

Although long-term results are necessary to determine the benefits of the procedure, early results indicate that LSG may be a safe and feasible option for treating the morbidly obese patients.

Videoendoscopically assisted combined retroperitoneal and pelvic extraperitoneal approach for aortoiliac occlusive disease

BACKGROUND

Laparoendoscopic surgery has emerged as a new method for the management of iliac and aortoiliac occlusive disease. This article describes a combined retroperitoneal and pelvic extraperitoneal approach to aorta and iliac arteries.

METHODS

A review was performed for 15 patients who underwent videoendoscopically assisted vascular bypass procedures between January 1999 and June 2003. A minimal access approach was used for access to the proximal anastomotic site (proximal common iliac or distal aorta) and creation of a tunnel for the prosthetic graft placement up to the distal anastomotic site. Altogether, 11 iliofemoral bypasses, 2 iliobifemoral bypasses and 2 aortobifemoral bypasses were performed. Patients with diffuse stenosis/long-segment occlusion and multiple lesions for whom percutaneous transluminal angioplasty with stenting proved to be unsuitable were included. The outcome parameters measured were intraoperative time, intraoperative blood loss, skin incision length, length of hospital stay, postoperative pain and analgesia requirement, and patency of graft.

RESULTS

Videoendoscopy was used to complete 14 procedures. The mean operating time was 258 +/- 49 min (range, 180-300 min) and the mean blood loss was 124 +/- 28.23 ml (range, 80-150 ml). The mean hospital stay was 6.7 +/- 4.46 days (range, 4-9 days). After a mean follow-up period of 14.4 +/- 3.55 months (range, 6-20 months), all grafts were patent.

CONCLUSION

Videoendoscopically assisted vascular surgery for iliac and aortoiliac occlusive disease by a combined retroperitoneal and pelvic extraperitoneal approach is feasible and appears to confer many advantages of minimal access surgery. However, prospective randomized trials are needed to define clearly any advantages of this approach over conventional surgery.

Laparoscopic hepaticojejunostomy for biliary strictures: the experience of 10 patients

Hepaticojejunostomy is performed to reestablish bilioenteric continuity. During a 5-year period between July 1998 and July 2003, the authors attempted hepaticojejunostomy by a total laparoscopic approach in 10 patients with benign stricture disorders of the extrahepatic biliary tree. Six of these patients had type 1 (extrahepatic, fusiform) choledochal cyst and presented with pain, fever, and jaundice. Four of the patients had iatrogenic biliary strictures after cholecystectomy (2 patients after laparoscopic cholecystectomy and 2 patients after open cholecystectomy). These patients had a variable presentation 1 to 3 weeks after the primary procedure, with peritonitis and/or cholangitis or only progressive jaundice. For nine of the patients (90%), the procedure was completed entirely laparoscopically. The mean operative time was 326.6 min for the patients with choledochal cysts and 268 min for the patients with iatrogenic strictures. One patient with stricture after open cholecystectomy underwent conversion to an open repair because of severe anatomic distortion and fibrosis. Four patients drained bile postoperatively for 5 to 7 days. One patient with iatrogenic biliary stricture after open cholecystectomy required open revision of the anastomosis 18 months after laparoscopic hepaticojejunostomy because of recurrent cholangitis. The remaining eight patients (80%) were doing well a mean follow-up period of 3.1 years (range, 3 months to 5 years). Total laparoscopic hepaticojejunostomy is feasible for a select group of patients, but requires advanced laparoscopic skills, including intracorporeal suturing. It must be attempted only in centers well versed in advanced laparoscopic surgery.

Minimal access surgery for hydatid cyst disease: laparoscopic, thoracoscopic, and retroperitoneoscopic approach

Surgery has remained the mainstay for the treatment of hydatid cyst. The rapid development of laparoscopic techniques has encouraged surgeons to replicate principles of conventional hydatid surgery using a minimally invasive approach. Several reports have confirmed the feasibility of laparoscopic hepatic hydatid surgery. We report the use of a laparoscopic approach for cysts located in the liver, lung, and retroperitoneum. Fifteen patients with hydatid cysts, including one patient with a recurrent cyst, of various organs, including the liver, lung, and retroperitoneum, were operated on laparoscopically. Sixteen hydatid cysts were drained in a total of 15 patients. The mean operative time was 84 +/- 6 minutes (60-125 minutes). The mean duration of the hospital stay was 2.3 days (1-6 days). The mean cyst diameter was 9.2 cm (6.4-13.5 cm). No conversions to open surgery were required. One complication, a trocar-induced bowel perforation, occurred, and there was no mortality. During 3 to 44 months (mean, 27 months) of follow-up, no recurrences developed. Minimal access surgery is a safe, effective, and viable option for the management of selected patients with hydatid cysts in various locations, such as the liver, lung, and retroperitoneum.

Extraperitoneal endoscopic groin hernia repair under epidural anesthesia

We performed a prospective study to evaluate the feasibility of performing endoscopic total extraperitoneal repair of groin hernia (TEP) under epidural anesthesia in selected patients considered to be at high risk or unfit for general anesthesia. Fifty-eight endoscopic total extraperitoneal hernia repairs were performed in 36 patients between January 1997 and December 1999 under epidural anesthesia since they were considered a high risk or unfit for general anesthesia. All patients received intramuscular diclofenac sodium for preemptive analgesia. Intraoperatively, all were sedated with intravenous midazolam and fentanyl. Endoscopic TEP repair was successful under epidural anesthesia in 33 of 36 patients. In the remaining three patients, the procedure had to be converted to Lichtenstein's repair due to shoulder discomfort experienced by the patients as a result of pneumoperitoneum, which was produced by incidental peritoneal tears during extraperitoneal dissection. Intraoperatively, one patient had bleeding from the inferior epigastric artery, which was controlled with clipping of the artery. The mean operative time was 48 minutes (range, 28-72 minutes) in the TEP group and 94 minutes (range, 84-102 minutes) in the converted group. All the patients received an epidural top-up dose at the end of surgery for postoperative analgesia. All patients were ambulatory the same day. Postoperative pain was assessed by a visual analogue scale (VAS). The mean pain score was 1.2 (+/- 0.8) on discharge in the TEP group. During follow-up, seven patients developed scrotal swelling with cord induration, which was treated conservatively with scrotal support and analgesics. In all patients, resolution was observed within 6 weeks. One patient was detected to have a recurrence 4 months after surgery. Endoscopic TEP repair under epidural anesthesia appears to be safe, technically feasible, and an acceptable alternative in patients who are at high risk or unfit for general anesthesia.

Laparoscopic intragastric stapled cystogastrostomy for pancreatic pseudocyst

BACKGROUND

Mature symptomatic pancreatic pseudocysts require surgical intervention for their management. In this era of minimal access surgery, several reports are now available of laparoscopic management of pancreatic pseudocysts.

PATIENTS AND METHODS

We have performed this procedure in five patients over the past 2 years. Four patients developed the pseudocyst after acute alcoholic pancreatitis and one following acute biliary pancreatitis. The diameter of the pseudocyst ranged from 8 to 12 cm. The procedure was performed using five ports. The Harmonic Scalpel was used to create two ports in the anterior stomach wall through which two balloon trocars were placed into the gastric lumen. Following balloon inflation, the trocars were used to lift up the anterior gastric wall. This created the space for the cystogastrostomy to be fashioned laparoscopically through the balloon trocar. The ball probe of the Harmonic Scalpel was used to puncture the cyst through the posterior gastric wall. The cystogastrostomy was completed by firing an Endo-GIA30 stapler across the fused posterior gastric wall and anterior wall of the cyst.

RESULTS

The mean operative time was 90 minutes (range 80-125 minutes). The mean postoperative stay was 3.0 days. One patient had intraoperative bleeding at the anastomotic site, which was easily controlled.

CONCLUSION

Laparoscopic cystogastrostomy offers a feasible and safe therapeutic option for selected patients with large symptomatic pancreatic pseudocysts.

Laparoscopic ventral hernia repair

PURPOSE

A retrospective study was carried out of patients who underwent laparoscopic ventral abdominal wall hernia repair (excluding groin hernias) between January 1994 and January 1999.

PATIENTS AND METHODS

Laparoscopic ventral hernia repair was performed on 202 patients for defects ranging from 1.5 cm to 12 cm in diameter. Of these, 35 patients had multiple hernial defects. After reduction of the hernial contents and adhesiolysis, a polypropylene mesh was used intraperitoneally in all patients, such that there was a margin of at least 3 cm from the edge of the defect as well as the previous scar.

RESULTS

The mean operating time decreased from 90 minutes in the initial 3 years to 50 minutes in the last 2 years. Postoperatively, the mean hospital stay was 1.8 days. Patients complained of somatic abdominal pain at the site of mesh insertion for a mean of 7 days. There were two postoperative hernia recurrences at a mean follow-up of 2.9 years. The incidence of seroma formation postoperatively was 32% in the first 3 years but declined to 18% subsequently with postoperative abdominal-wall pressure dressings. There were no postoperative sequelae related to bowel adhesions. Negligible wound sepsis (superficial wound infection in five patients), decreased morbidity, and all the other advantages of a minimally invasive surgical approach were evident in this group of patients.

CONCLUSION

These promising early results need to be confirmed by a prospective controlled trial, especially recurrence rates and incidence of postoperative adhesions.

Laparoscopic subtotal cholecystectomy: a review of 56 procedures

BACKGROUND AND PURPOSE

The essential surgical steps in laparoscopic cholecystectomy remain similar to those of open cholecystectomy. Positive identification of the biliary anatomy, safe clipping or ligature of the cystic duct and artery, and dissection of the gallbladder from the liver bed form the basis of cholecystectomy. Subtotal cholecystectomy is a definitive and safe operation under certain adverse conditions intraoperatively for dissection of the gallbladder from the liver bed. We reviewed our experience with laparoscopic cholecystectomy over a 2-year period between June 1996 and May 1998, when 1,680 operations were performed. The objective was to analyze the pathology, review surgical procedures, and trace the outcome of laparoscopic subtotal cholecystectomy.

PATIENTS AND METHODS

In 56 of 1,680 patients, laparoscopic subtotal cholecystectomy was performed, which constituted 3.33% of the laparoscopic cholecystectomies performed at our institution. Dense fibrosis and adhesions were present in 32 patients; 12 patients had Mirizzi syndrome, 6 patients had a sessile gallbladder, and 6 patients had a gangrenous gallbladder. The Endo-GIA 30 stapler was used in 40 patients, sequential clips were used in 9 patients, and a suture for stump closure was used in 5 patients. A subhepatic drain was inserted in 50 patients.

RESULTS

Two conversions to open surgery were needed because of gangrene of the gall bladder wall and one conversion as a result of continued bleeding from the cystic artery after application of the Endo-GIA 30 stapler. The mean postoperative stay in hospital was 2.5 days. One patient had a solitary bile duct calculus extracted at endoscopic retrograde cholangiopancreatography 3 months after surgery. Three patients had biliary drainage that lasted for a week, and four patients had epigastric port-site infections that resolved with antibiotics, dressings and postural drainage.

CONCLUSION

Laparoscopic subtotal cholecystectomy is safe, feasible, and effective and may help prevent conversion to open surgery in carefully selected patients with difficult cholecystectomies.

The management of Mirizzi syndrome in the laparoscopic era

Mirizzi syndrome is a rare complication of long-standing gallstone disease resulting in obstructive jaundice. Careful perioperative management is of utmost importance because of an increased risk of bile duct injury intraoperatively. Experience with Mirizzi syndrome over a period of 3 years, from January 1996 to December 1998, was reviewed. Twenty-seven patients were operated upon, which constituted 0.9% of 2840 patients who underwent laparoscopic cholecystectomy in the authors' department. There were 12 patients with Mirizzi type I syndrome and 15 patients with Mirizzi type II syndrome, according to McSherry classification. Six (22%) conversions were reported, all because of unclear anatomy and inherent limitations of the laparoscopic approach. For the remaining 21 (78%) patients, the procedure was completed laparoscopically. No bilioenteric anastomosis was required. A preoperative stent insertion in the common bile duct (CBD) during endoscopic retrograde cholangiopancreatography (ERCP) enabled us to achieve primary closure of CBD in every case. There was no perioperative mortality, and patients remained well for an average 2.1-year follow-up. It is highly desirable to have a preoperative diagnosis of Mirizzi syndrome, and the laparoscopic approach is not a contraindication in specialized centers. Our current management protocol to treat Mirizzi syndrome consists of a high degree of suspicion at ERCP, with stenting preoperatively and a complete stone clearance with subtotal cholecystectomy intraoperatively.

Endoscopic neck surgery: expanding horizons

There have now been several attempts at neck exploration using minimally invasive surgery. These encouraging reports paved the way for the authors to attempt endoscopic neck surgery. Having the necessary technical expertise in minimally invasive surgery with an experience of more than 6000 laparoscopic procedures, they attempted endoscopic parathyroidectomy in three patients with hyperparathyroidism. Of these, two had a hyperfunctioning adenoma and one had parathyroid hyperplasia. The hyperfunctioning tissue was accurately localized using a 99Tc-thallium subtraction scan. It was possible to localize and dissect the parathyroid tissue in two of the three patients. One patient required an open hemithyroidectomy before the adenoma could be localized and excised. The total operative time averaged 113 min. The working space was found to be adequate provided good hemostasis was maintained. The magnification proved excellent in identifying and defining important neck structures. Sufficient mobilization of the lateral thyroid lobe for access to the tracheoesophageal groove was found to be technically very difficult. No subcutaneous emphysema was observed beyond the neck region, and none lasted beyond 24 h. Cosmesis was acceptable to both the patient and the surgeon.

Prolong continuous versus weekly oral acyclovir in recurrent herpes genitalis

Patients with frequent recurrences of genital herpes were treated with oral acyclovir tablet, 800 mg once daily or once a week for 2 years. Confirmed recurrences for all patients were treated with acyclovir, 200 mg orally 5 times per day, for five days. Of 58 patients enrolled, 12 of 26 daily acyclovir recipients and 22 of 32 weekly acyclovir recipients completed two years of study. Patients receiving daily acyclovir experienced a mean of 0.0991 recurrences / month compared with mean of 0.113 recurrences / month for patients receiving weekly acyclovir. A total of 33% of daily acyclovir recipients and 27% weekly acyclovir recipients were free of recurrences for two years.

Incontinentia pigmenti

Three cases of incontinentia pigmenti are reported. All the patients were female with bizarre pigmentation and verrucous and nodular lesions on the body. In all the cases there was absence of the vesicular stage and systemic involvement.

Coexistance of Subcorneal Pustular Dermatosis and Lepromatous Leprosy

A case of lepromatous leprosy having lesions of subcorneal pustular dermatosis is reported. This association supports the gypothesis that immunological factors are involved in the pathogenesis of SCPD.